Assessment and Health Promotion

Assessment and Health Promotion

Deitra Leonard Lowdermilk

Key Terms and Definitions

Web Resources

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Many women initially enter the health care system because of some reproductive system–related situation, such as pregnancy; irregular menses; desire for contraception; or episodic illness, such as vaginal infection. Once women are in the system, however, one of the health care provider’s responsibilities is to recognize the need for health promotion and preventive health maintenance and to provide these services as part of lifelong care for women. This chapter reviews female anatomy and physiology, including the menstrual cycle. It also covers physical assessment and screening for disease prevention for women in their reproductive years. In addition, the chapter discusses barriers to seeking health care and gives an overview of conditions and circumstances that increase health risks in the childbearing years. Anticipatory guidance suggestions for health promotion and prevention are also included.

Female Reproductive System image

External Structures

The external genital organs, or vulva, include all structures visible externally from the pubis to the perineum (Fig. 2-1). The mons pubis is a fatty pad that lies over the anterior surface of the symphysis pubis. In the postpubertal woman, the mons is covered with coarse curly hair. The labia majora are two rounded folds of fatty tissue covered with skin that extend downward and backward from the mons pubis. These folds are highly vascular structures that develop hair on the outer surfaces after puberty and protect the inner vulvar structures. The labia minora are two flat, reddish folds of tissue visible when the labia majora are separated. Anteriorly, they fuse to form the prepuce (a hoodlike covering of the clitoris) and the frenulum (a fold of tissue under the clitoris). The labia minora join to form a thin flat tissue called the fourchette underneath the vaginal opening at the midline. The clitoris is a small structure composed of erectile tissue with numerous sensory nerve endings located underneath the prepuce.

The vaginal vestibule is an almond-shaped area enclosed by the labia minora that contains openings to the urethra, Skene glands, vagina, and Bartholin glands. The urethra is not a reproductive organ but is considered here because of its location. Usually this structure is approximately 2.5 cm below the clitoris. The Skene glands are located on each side of the urethra and produce mucus, which aids in lubrication of the vagina. The vaginal opening is in the lower portion of the vestibule and varies in shape and size. The hymen, a connective tissue membrane, surrounds the vaginal opening. Bartholin glands (see Fig. 2-1) lie under the constrictor muscles of the vagina and are located posteriorly on the sides of the vaginal opening, although the ductal openings are not usually visible. During sexual arousal the glands secrete clear mucus to lubricate the vaginal introitus.

The area between the fourchette and the anus is the perineum, a skin-covered muscular area that covers the pelvic structures. The perineum forms the base of the perineal body, a wedged-shaped mass that serves as an anchor for the muscles, fascia, and ligaments of the pelvis. The pelvic organs are supported by muscles and ligaments that form a sling.

Internal Structures

The internal structures include the vagina, uterus, uterine tubes, and ovaries. The vagina is a fibromuscular, collapsible tubular structure that extends from the vulva to the uterus and lies between the bladder and rectum. During the reproductive years the mucosal lining is arranged in transverse folds called rugae. These rugae allow the vagina to expand during childbirth. Estrogen deprivation that occurs after childbirth, during lactation, and at menopause causes dryness and thinness of the vaginal walls and smoothing of the rugae. Vaginal secretions are acidic (pH 4 to 5), which reduces the vagina’s susceptibility to infections. The vagina serves as a passageway for menstrual flow, as a female organ of copulation, and as a part of the birth canal for vaginal childbirth. The uterine cervix projects into a blind vault at the upper end of the vagina. Anterior, posterior, and lateral pockets called fornices surround the cervix. The internal pelvic organs can be palpated through the thin walls of these fornices.

The uterus is a muscular organ shaped like an upside-down pear that sits midline in the pelvic cavity between the bladder and the rectum above the vagina. Four pairs of ligaments support the uterus: the cardinal, uterosacral, round, and broad. Single anterior and posterior ligaments also support the uterus. The cul-de-sac of Douglas is a deep pouch, or recess, posterior to the cervix and formed by the posterior ligament.

The uterus is divided into two major parts: an upper triangular portion called the corpus and a lower cylindric portion called the cervix (Fig. 2-2). The fundus is the dome-shaped top of the uterus and is the site where the uterine tubes enter the uterus. The isthmus (lower uterine segment) is a short, constricted portion that separates the corpus from the cervix.

The uterus serves many purposes. It receives and implants the fertilized ovum and nourishes it throughout the pregnancy. During childbirth, the uterus is responsible for the expulsion of the fetus. It also is the organ for cyclic menstruation.

The uterine wall consists of three layers: the endometrium, the myometrium, and part of the peritoneum. The endometrium is a highly vascular lining made up of three layers, the outer two of which are shed during menstruation. The myometrium is made up of layers of smooth muscles that extend in three different directions (longitudinal, transverse, and oblique) (Fig. 2-3). Longitudinal fibers of the outer myometrial layer are mostly in the fundus, and this arrangement assists in expelling the fetus during the birth process. The middle layer contains fibers from all three directions, which form a figure-eight pattern encircling large blood vessels. This arrangement assists in constricting blood vessels after childbirth and controls blood loss. Most of the circular fibers of the inner myometrial layer are around the site where the uterine tubes enter the uterus and around the internal cervical os (opening). These fibers help keep the cervix closed during pregnancy and prevent menstrual blood from flowing back into the uterine tubes during menstruation.

The cervix is made up of mostly fibrous connective tissues and elastic tissue, enabling it to stretch during vaginal childbirth. The opening between the uterine cavity and the canal that connects the uterine cavity to the vagina (endocervical canal) is the internal os. The narrowed opening between the endocervix and the vagina is the external os, a small circular opening in women who have never been pregnant. The cervix feels firm (similar to the end of a nose) with a dimple in the center, which marks the external os.

The outer cervix is covered with a layer of squamous epithelium. The mucosa of the cervical canal is covered with columnar epithelium and contains numerous glands that secrete mucus in response to ovarian hormones. The squamocolumnar junction, where the two types of cells meet, is usually just inside the cervical os. This junction is also called the transformation zone and is the most common site for neoplastic changes. Cells from this site are scraped for the Papanicolaou (Pap) test (or smear) (see p. 51).

The uterine (fallopian) tubes attach to the uterine fundus. Broad ligaments support these tubes that range from 8 to 14 cm in length. The uterine tubes provide a passage between the ovaries and the uterus for the passage of the ovum.

The ovaries are almond-shaped organs located on each side of the uterus below and behind the uterine tubes. During the reproductive years, they are approximately 3 cm long, 2 cm wide, and 1 cm thick. They diminish in size after menopause. The two functions of the ovaries are ovulation and production of estrogen, progesterone, and androgen.

Bony Pelvis

The bony pelvis serves three primary purposes: protection of the pelvic structures, accommodation of the growing fetus during pregnancy, and anchorage of the pelvic support structures. Two innominate (hip) bones (consisting of the ilium, ischium, and pubis), the sacrum, and the coccyx make up the four bones of the pelvis (Fig. 2-4). Cartilage and ligaments form the symphysis pubis, sacrococcygeal, and two sacroiliac joints that separate the pelvic bones. The pelvis is divided into two parts: the false pelvis and the true pelvis (Fig. 2-5). The false pelvis is the upper portion above the pelvic brim or inlet. The true pelvis is the lower curved bony canal, which includes the inlet, the cavity, and the outlet through which the fetus passes during vaginal birth. Variations that occur in the size and shape of the pelvis are usually a result of age, race, and injury. Pelvic ossification is complete by approximately 20 years of age.


The breasts are paired mammary glands located between the second and sixth ribs (Fig. 2-6). Approximately two thirds of the breast overlies the pectoralis major muscle, between the sternum and midaxillary line, with an extension to the axilla referred to as the tail of Spence. The lowest third of the breast lies over the serratus anterior muscle. Connective tissue called fascia attach the breast to the muscles.

The breasts of healthy mature women are approximately equal in size and shape but are often not absolutely symmetric. The size and shape vary depending on the woman’s age, heredity, and nutrition. However, the contour should be smooth with no retractions, dimpling, or masses. Estrogen stimulates growth of the breast by inducing fat deposition in the breasts, development of stromal tissue (i.e., an increase in its amount and elasticity), and growth of the extensive ductile system. Estrogen also increases the vascularity of breast tissue. The increase in progesterone at puberty causes maturation of mammary gland tissue, specifically the lobules and acinar structures. During adolescence, fat deposition and growth of fibrous tissue contribute to the increase in the gland’s size.

Findings from several studies using ultrasound imaging to investigate the anatomy of the breast found differences from previous descriptions (Geddes, 2007; Love & Barsky, 2004; Ramsay, Kent, Hartmann, & Hartmann, 2005). Each mammary gland is made of a number of lobes, which are divided into lobules. Lobules are clusters of acini. An acinus is a saclike terminal part of a compound gland emptying through a narrow lumen or duct. The acini are lined with epithelial cells that secrete colostrum and milk. Just below the epithelium is the myoepithelium (myo, or muscle), which contracts to expel milk from the acini.

The ducts from the clusters of acini that form the lobules merge to form larger ducts draining the lobes. Ducts from the lobes converge in a single nipple (mammary papilla) surrounded by an areola. The anatomy of the ducts is similar for each breast but varies among women. Protective fatty tissue surrounds the glandular structures and ducts. Cooper’s ligaments, or fibrous suspensory, separate and support the glandular structures and ducts. Cooper’s ligaments provide support to the mammary glands while permitting their mobility on the chest wall (see Fig. 2-6). The round nipple is usually slightly elevated above the breast. On each breast the nipple projects slightly upward and laterally. It contains 4 to 20 openings from the milk ducts. The nipple is surrounded by fibromuscular tissue and covered by wrinkled skin (the areola). Except during pregnancy and lactation, there is usually no discharge from the nipple.

The nipple and surrounding areola are usually more deeply pigmented than the skin of the breast. Sebaceous glands called Montgomery tubercles directly beneath the skin (see Fig. 2-6) give the areola its rough appearance. These glands secrete a fatty substance thought to lubricate the nipple.

The vascular supply to the mammary gland is abundant. The skin covering the breasts contains an extensive superficial lymphatic network that serves the entire chest wall and is continuous with the superficial lymphatics of the neck and abdomen. In the deeper portions of the breasts, the lymphatics form a rich network as well. The primary deep lymphatic pathway drains laterally toward the axillae.

The breasts change in size and nodularity in response to cyclic ovarian changes throughout reproductive life. Increasing levels of both estrogen and progesterone in the 3 to 4 days before menstruation increase vascularity of the breasts, induce growth of the ducts and acini, and promote water retention. As a result, breast swelling, tenderness, and discomfort are common symptoms just before the onset of menstruation. After menstruation, cellular proliferation begins to regress, acini begin to decrease in size, and retained water is lost. In time, after repeated hormonal stimulation, small persistent areas of nodulations may develop just before and during menstruation, when the breast is most active. The physiologic alterations in breast size and activity reach their minimal level approximately 5 to 7 days after menstruation stops. The best time for a woman who wishes to perform a breast self-examination (BSE) is during this phase of the menstrual cycle or whenever the breasts are not tender or swollen (see Patient Instructions for Self-Management box).

Patient Instructions for Self-Management

Breast Self-Examination

If you choose to perform a breast self-examination, the best time is when breasts are not tender or swollen.

How to examine your breasts:

1. Lie down and put a pillow under your right shoulder. Place your right arm behind your head (Fig. 1).

Fig. 1

2. Use the finger pads of your three middle fingers on your left hand to feel for lumps or thickening. Your finger pads are the top third of each finger. Use circular motions of the finger pads to feel the breast tissue.

3. Press firmly enough to know how your breast feels. Use light pressure to feel the tissue just under the skin, medium pressure for a little deeper, and firm pressure to feel the breast tissue close to the chest and ribs. A firm ridge in the lower curve of the breast is normal.

4. Move around the breast in a set way, such as using an up and down or vertical line pattern (Fig. 2). Go up to the collar bone and down to the ribs and from your underarm on the side to the middle of your chest. Use the same technique every time. It will help you to make sure that you have gone over the entire breast area and to remember how your breast feels.

Fig. 2

5. Now examine your left breast using the finger pads of your right hand.

6. You may want to check your breasts while standing in front of a mirror. See if there are any changes in the way your breasts look: dimpling of the skin, changes in the nipple, or redness or swelling.

7. You may also want to perform an extra breast self-examination while you are in the shower (Fig. 3). Your soapy hands will glide over the wet skin, making it easy to check how your breasts feel.

Fig. 3

8. Checking the area between the breast and the underarm and the underarm itself is important. Examine the area above the breast to the collarbone and to the shoulder while you are standing or sitting up with your arms lightly raised.

9. If you find any changes, see your health care provider right away.

Source: American Cancer Society. (2008). How to perform a breast self-exam. Internet document available at (accessed June 4, 2009).

Evidence-Based Practice

Teaching Women Breast Self-Examination: Is It Worthwhile?

Critically Analyze the Data

The ideal screening test for breast cancer would have a high sensitivity for breast cancer in an early, curable stage, thus decreasing mortality. Moreover, it would have a high specificity, meaning few false positives and thus few unnecessary diagnostic tests. Screening for breast cancer has conventionally consisted of a BSE monthly, a clinical breast examination (CBE) yearly, and a screening mammogram every 1 to 2 years after 40 years of age. Of these, the screening mammogram has been the gold standard, responsible for a 15% to 20% decrease in mortality in a metaanalysis of seven trials, representing one half million women (Gotzsche & Nielsen, 2006). Mammograms are limited by their cost, discomfort, geographic availability, skilled interpretation, exposure to radiation, and high false-positive rates.

Mammograms are usually accompanied by a CBE given by a trained examiner. Since the 1970s, women were also routinely taught to perform a BSE. The assumption was that BSE was a low-tech screening tool for women to detect tumors in the early, more treatable stages. This theory was challenged by a classic metaanalysis of two randomized controlled trials involving 388,535 women in Russia and Shanghai, which found no difference in cancer mortality between groups taught BSE and control groups without the BSE education (Kosters & Gotzche, 2003, updated 2007). In fact, the BSE group was twice as likely to undergo unnecessary biopsy with benign results as the control group. The authors noted poor compliance with breast examinations but commented about the possibility that BSE may have decreased mortality in some countries.

Breast cancer screening recommendations from the National Cancer Institute (NCI) include a CBE and a screening mammogram (National Cancer Institute, 2007). The NCI organization guidelines note that BSE alone has not been shown to reduce mortality but do encourage women to be alert to any changes in their breasts and report them to their health care provider.


Menstrual cycle

Initially, menstrual periods are irregular, unpredictable, painless, and anovulatory. After the ovary produces adequate cyclic estrogen to make a mature ovum, periods tend to be regular and ovulatory. The menstrual cycle is a complex interplay of events that occur simultaneously in the endometrium, hypothalamus and pituitary glands, and ovaries. The menstrual cycle prepares the uterus for pregnancy. When pregnancy does not occur, menstruation follows. Menstruation is the periodic uterine bleeding that begins approximately 14 days after ovulation. The average length of a menstrual cycle is 28 days, but variations are common. The first day of bleeding is designated as day 1 of the menstrual cycle, or menses (Fig. 2-7). The average duration of menstrual flow is 5 days (range of 1 to 8 days), and the average blood loss is 50 ml (range of 20 to 80 ml), but these vary greatly (Fehring, Schneider, & Raviele, 2006). The woman’s age, physical and emotional status, and environment also influence the regularity of her menstrual cycles.

Hypothalamic-pituitary cycle.

Toward the end of the normal menstrual cycle, blood levels of estrogen and progesterone fall. Low blood levels of these ovarian hormones stimulate the hypothalamus to secrete gonadotropin-releasing hormone (GnRH). In turn, GnRH stimulates anterior pituitary secretion of follicle-stimulating hormone (FSH) that stimulates development of ovarian graafian follicles and their production of estrogen. Estrogen levels begin to fall, and hypothalamic GnRH triggers the anterior pituitary release of luteinizing hormone (LH). A marked surge of LH and a smaller peak of estrogen (day 12; see Fig. 2-7) precede the expulsion of the ovum (ovulation) from the graafian follicle by approximately 24 to 36 hours. LH peaks at approximately the thirteenth or fourteenth day of a 28-day cycle. If fertilization and implantation of the ovum do not occur by this time, the corpus luteum regresses. Levels of progesterone and estrogen decline, menstruation occurs, and the hypothalamus is once again stimulated to secrete GnRH. This process is the hypothalamic-pituitary cycle.

Ovarian cycle.

The primitive graafian follicles contain immature oocytes (primordial ova). Before ovulation, from 1 to 30 follicles begin to mature in each ovary under the influence of FSH and estrogen. The preovulatory surge of LH affects a selected follicle. The oocyte matures, ovulation occurs, and the empty follicle begins its transformation into the corpus luteum. This follicular phase (preovulatory phase) (see Fig. 2-7) of the ovarian cycle varies in length from woman to woman and accounts for almost all variations in ovarian cycle length (Fehring et al., 2006). On rare occasions (approximately 1 in 100 menstrual cycles), more than one follicle is selected and more than one oocyte matures and undergoes ovulation.

After ovulation, estrogen levels drop. For 90% of women, only a small amount of withdrawal bleeding occurs, so it goes unnoticed. In 10% of women bleeding is sufficient for it to be visible, resulting in what is known as midcycle bleeding.

The luteal phase begins immediately after ovulation and ends with the start of menstruation. This postovulatory phase of the ovarian cycle usually requires 14 days (range of 13 to 15 days). The corpus luteum reaches its peak of functional activity 8 days after ovulation, secreting both estrogen and progesterone. Coincident with this time of peak luteal functioning, the fertilized ovum is implanted in the endometrium. If no implantation occurs, the corpus luteum regresses, steroid levels drop, and menstruation occurs.

Endometrial cycle.

The endometrial cycle is divided into four phases (see Fig. 2-7). During the menstrual phase, shedding of the functional two thirds of the endometrium (the compact and spongy layers) is initiated by periodic vasoconstriction in the upper layers of the endometrium. The basal layer is always retained, and regeneration begins near the end of the cycle from cells derived from the remaining glandular remnants or stromal cells in the basalis.

The proliferative phase is a period of rapid growth lasting from approximately the fifth day to the time of ovulation. The endometrial surface is completely restored in approximately 4 days, or slightly before bleeding ceases. From this point on, an eightfold to tenfold thickening occurs, with a leveling off of growth at ovulation. The proliferative phase depends on estrogen stimulation derived from ovarian follicles.

The secretory phase extends from the day of ovulation to approximately 3 days before the next menstrual period. After ovulation, larger amounts of progesterone are produced. The fully matured secretory endometrium reaches the thickness of heavy, soft velvet. It becomes luxuriant with blood and glandular secretions, a suitable protective and nutritive bed for a fertilized ovum.

Implantation of the fertilized ovum generally occurs approximately 7 to 10 days after ovulation. If fertilization and implantation do not occur, the corpus luteum, which secretes estrogen and progesterone, regresses. With the rapid fall in progesterone and estrogen levels, the spiral arteries go into spasm. During the ischemic phase, the blood supply to the functional endometrium is blocked, and necrosis develops. The functional layer separates from the basal layer, and menstrual bleeding begins, marking day 1 of the next cycle (see Fig. 2-7).


The climacteric is a transitional phase during which ovarian function and hormone production decline. This phase spans the years from the onset of premenopausal ovarian decline to the postmenopausal time when symptoms stop. Menopause refers to the last menstrual period. Unlike menarche, however, menopause can be dated only with certainty 1 year after menstruation ceases. The average age at natural menopause is 51 to 52 years, with an age range of 35 to 60 years. Menopause is preceded by a period known as the perimenopause, during which ovarian function declines. Ova slowly diminish, and menstrual cycles are anovulatory, resulting in irregular bleeding; the ovary stops producing estrogen, and eventually menses no longer occurs. This period lasts approximately 5 years (range 2-8 years) (Speroff & Fritz, 2005).

Sexual Response

The hypothalamus and anterior pituitary gland in females regulate the production of FSH and LH. The target tissue for these hormones is the ovary, which produces ova and secretes estrogen and progesterone. A feedback mechanism involving hormone secretion from the ovaries, hypothalamus, and anterior pituitary aids in the control of the production of sex cells and steroid sex hormone secretion.

Sexual stimulation results in vasocongestion (congestion of blood vessels, usually venous) that causes vaginal lubrication and engorgement and distention of the genitals. This venous congestion occurs to a lesser degree in the breasts and other parts of the body. Arousal is characterized by myotonia (increased muscular tension), resulting in voluntary and involuntary rhythmic contractions. Examples of sexually stimulated myotonia are pelvic thrusting, facial grimacing, and spasms of the hands and feet (carpopedal spasms).

The sexual response cycle is divided into four phases: excitement phase, plateau phase, orgasmic phase, and resolution phase. The four phases occur progressively, with no sharp dividing line between any two phases. Specific body changes take place in sequence. The time, intensity, and duration for cyclic completion also vary for individuals and situations. Table 2-1 compares male and female body changes during each of the four phases of the sexual response cycle.


Four Phases of Sexual Response

Heart rate and blood pressure increase. Nipples become erect. Myotonia begins. Clitoris increases in diameter and swells. External genitals become congested and darken. Vaginal lubrication occurs; upper two thirds of vagina lengthen and extend. Cervix and uterus pull upward. Breast size increases. Erection of the penis begins; penis increases in length and diameter. Scrotal skin becomes congested and thickens. Testes begin to increase in size and elevate toward the body.
Heart rate and blood pressure continue to increase. Respirations increase. Myotonia becomes pronounced; grimacing occurs. Clitoral head retracts under the clitoral hood. Lowest third of vagina becomes engorged. Skin color changes occur—red flush may be observed across breasts, abdomen, or other surfaces. Head of penis may enlarge slightly. Scrotum continues to grow tense and thicken. Testes continue to elevate and enlarge. Preorgasmic emission of two or three drops of fluid appears on the head of the penis.
Heart rate, blood pressure, and respirations increase to maximal levels. Involuntary muscle spasms occur. External rectal sphincter contracts. Strong rhythmic contractions are felt in the clitoris, vagina, and uterus. Sensations of warmth spread through the pelvic area. Testes elevate to maximal level. Point of “inevitability” occurs just before ejaculation and an awareness of fluid in the urethra. Rhythmic contractions occur in the penis. Ejaculation of semen occurs.
Heart rate, blood pressure, and respirations return to normal. Nipple erection subsides. Myotonia subsides. Engorgement in external genitalia and vagina resolves. Uterus descends to normal position. Cervix dips into seminal pool. Breast size decreases. Skin flush disappears. Fifty percent of erection is lost immediately with ejaculation; penis gradually returns to normal size. Testes and scrotum return to normal size. Refractory period (time needed for erection to occur again) varies according to age and general physical condition.


Reasons for Entering the Health Care System image

Women’s health assessment and screening focus on a systems evaluation beginning with a thorough history and physical examination. During the assessment and evaluation, the responsibility for self-management, health promotion, and enhancement of wellness are emphasized. Nursing care includes assessment, planning, education, counseling, and referral as needed, as well as commendations for good self-management that the woman has practiced. This process enables women to make informed decisions about their own health care.

Preconception Counseling

Preconception health promotion provides women and their partners with information that is needed to make decisions about their reproductive future. Preconception counseling guides couples on how to prevent unintended pregnancies, stresses risk management, and identifies healthy behaviors that promote the well-being of the woman and her potential fetus (Moos, 2006).

All providers who treat women for well-woman care or other routine care should incorporate preconception health screening as part of the routine care for women of reproductive age (Johnson et al., 2006). The initiation of activities that promote healthy mothers and babies must occur before the period of critical fetal organ development, which is between 17 and 56 days after fertilization. By the end of the eighth week after conception and certainly by the end of the first trimester, any major structural anomalies in the fetus are already present. Because many women do not realize that they are pregnant and do not seek prenatal care until well into the first trimester, the rapidly growing fetus may be exposed to many types of intrauterine environmental hazards during this most vulnerable developmental phase.

Preconception care is important for women who have had a problem with a previous pregnancy (e.g., miscarriage, preterm birth). Although causes are not always identifiable, in many cases, problems can be identified and treated and may not recur in subsequent pregnancies. Preconception care is also important to minimize fetal malformations. For example, the woman may be exposed to teratogenic agents such as drugs, viruses, and chemicals, or she may have a genetically inherited disease. Preconception counseling can educate the woman about the effects of these agents and diseases, which can help prevent harm to the fetus or allow the woman to make an informed decision about her willingness to accept potential hazards should a pregnancy occur (Atrash, Johnson, Adams, Cordero, & Howse, 2006).

A model for preconception care of women of reproductive age targets all women from menarche to menopause at every encounter, not just in maternity and women’s health. Providing optimal health care for women whether or not they desire to conceive can result in a high level of preconception wellness (Moos, 2006). Suggested components of preconception care, such as health promotion, risk assessment, and interventions, are outlined in Box 2-1.

BOX 2-1   Components of Preconception Care

Risk Factor Assessment

• Chronic diseases

• Infectious diseases

• Reproductive history

• Genetic or inherited conditions (e.g., sickle cell anemia, Down syndrome, cystic fibrosis)

• Medications and medical treatment

• Personal behaviors and exposures

Fertility Control and Infertility

Almost half of the pregnancies in the United States each year are unintended even with birth control use (Trussell, 2007). Education is the key to encouraging women to make family planning choices based on preference and actual risk-to-benefit ratios. Women who enter the health care system seeking contraceptive counseling can be assisted to use a chosen method correctly (see Chapter 4 for further discussion).

Women also enter the health care system because of their desire to achieve a pregnancy. Approximately 15% of couples in the United States have some degree of infertility. Infertility can cause emotional pain for many couples, and the inability to produce an offspring sometimes results in feelings of failure and inordinate stress on the relationship. Steps toward prevention of infertility should be undertaken as part of ongoing routine health care, and such information is especially appropriate in preconception counseling. For additional information about infertility, see Chapter 4.

Barriers to Seeking Health Care image

Financial Issues

The United States spends more on health care than any other industrialized nation, yet major problems still exist. In the United States, disparity among races and socioeconomic classes affects many facets of life, including health. Limited money and awareness can lead to a lack of access to care, delay in seeking care, few prevention activities, and little accurate information about health and the health care system. Women use health services more often than do men but are more likely than men to have difficulty in financing the services. They are twice as often underinsured (i.e., they have limited coverage with high-cost co-payments or deductibles). Eighteen percent of women have no health insurance (National Women’s Law Center, 2007). Insurance coverage varies significantly by age, marital status, race, and ethnicity. Caucasians of all ages are more likely than African-Americans, Hispanics, and other racial or ethnic groups to have private insurance (Agency for Healthcare Research and Quality, 2005). Single, separated, or divorced individuals are less likely to have insurance. Often, unmarried teenagers, who are usually covered by their parents’ medical insurance, do not have maternity coverage because policies have inclusion statements that cover only the employee or spouse. More than twice as many women as men are insured by Medicaid (Patchias & Waxman, 2007). In most states, Medicaid includes special benefits for pregnant women, but they are limited to treatment of pregnancy-related conditions and terminated 60 days after the birth. Midwifery care has helped contain some health care costs, but reimbursement issues still exist in some areas.

Oct 8, 2016 | Posted by in NURSING | Comments Off on Assessment and Health Promotion

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